Intravenous Regional Block (Bier Block)

Indications: Surgery on the wrist, hand and fingers. Local anesthetic: 15 mL of 2% lidocaine Complexity level: Basic

General considerations Intravenous regional anesthesia was originally introduced by the German surgeon August K. G. Bier in 1908; thus the name, "Bier block". Dr. Bier described a complete anesthesia and motor paralysis after intravenous injection of prilocaine into a previously exsanguinated limb. The resultant anesthesia is produced by direct diffusion of the local anesthetic from the vessels into the nearby nerves. The technique was reintroduced into clinical practice using lidocaine as a local anesthetic in mid-1960s. Intravenous regional analgesia is best used for brief minor surgery (up to 1 hour) of the hand and forearm. Its use for longer surgical procedures is precluded by the appearance of the discomfort from the tourniquet, which limits the indications for its use. Some examples of suitable procedures include carpal tunnel release, tendon contracture release, and foreign body extraction. The main advantages of this technique are its simplicity and reliability. Its drawback is the lack of postoperative analgesia because the block quickly resolves after the release of the tourniquet. Injection of a local anesthetic solution into a venous system results in diffusion of the local anesthetic into the nerve endings with the consequent development of anesthesia. This holds true for as long as the concentration of the local anesthetic in the venous system remains relatively high. It is imperative that before the injection, the venous system is exsanguinated to prevent dilution of local anesthetic. Distribution of anesthesia Intravenous regional block results in anesthesia of the entire extremity below the level of the tourniquet. The duration of the anesthesia and analgesia are limited by the duration tourniquet. Tips The patient is in the supine position with the arm to be blocked elevated to achieve passive exsanguination

Nearly all cuffs will have some small-volume leaks. Therefore, a constant-pressure gas source (e.g., automatically-controlled source of nitrogen) is necessary to allow for inflation of the cuff or automatic correction of any leaks. The pneumatic cuffs should be checked for air leak before applying on the extremity

Technique A tourniquet is placed on the proximal arm of the extremity to be blocked. We use a "double cuff" to increase the reliability of the technique and help reduce the tourniquet pressure pain. Attention should be paid to generously wrapping the arm at the tourniquet site with a soft cloth to prevent discomfort on application of the tourniquet and skin bruising at the sites where the tourniquet may pinch the unprotected skin.

TIPS:

The use of a double tourniquet requires that the cuffs be narrower than the standard single cuffs (12-14 cm). The tourniquet is typically placed on the arm.

A small IV intravenous catheter (e.g, 22-gauge) is introduced in the dorsum of the patient's hand of the arm to be anesthetized. The catheter should be firmly taped in place to prevent its dislodgment during the exsanguination with the Esmarch or the injection procedure. The arm is then elevated and at least for 1 minute to allow passive exsanguination. Then, a 5" Esmarch is applied systematically from the finger tips to the distal cuff. Once the Esmarch is applied, the following maneuvers are undertaken to complete the exsanguination of the extremity: 1. Inflate the distal cuff. 2. Inflate the proximal cuff. 3. Deflate the distal cuff. The cuffs should be inflated to a pressure of 100 mm Hg above the systolic blood pressure, or at least 300 mm Hg. The Esmarch is then unwrapped and the extremity is checked for color (pale skin) and arterial occlusion (absence of the radial pulse). Choice of local anesthetic Lidocaine is the most commonly used drug for intravenous regional anesthesia. we prefer a smaller volume of a concentrated drug (e.g., 12-15 mL of 2% lidocaine). Block Dynamics and Perioperative Management The onset of anesthesia with this technique is within 5 minutes. The patient will typically report "pins and needles" in the extremity. However, this sign is almost always missed in our practice because we routinely administer small doses of midazolam (2-4 mg IV) to ensure the patient's comfort during the procedure. Most patients will invariably report pressure at the site of the tourniquet after 30-45 minutes; sometimes even earlier. When the discomfort becomes trouble-some and requires significant additional sedation and analgesics, the distal cuff over the anesthetized extremity is inflated and the proximal cuff is deflated. This provides immediate relief of discomfort due to the pressure from the proximal cuff. This maneuver will provide an additional 15-30 minutes of comfort. When tourniquet pain is first reported by the patient, the surgeon should be consulted for information on the expected time required to complete the surgery. The proximal tourniquet should not be released prematurely. The proper procedure for changing the tourniquet from the proximal to the distal cuff is as follows: 1. Inflate the distal cuff. 2. Check the pressure in the distal cuff by squeezing the cuff and documenting the oscillations on the manometer. 3. Deflate the proximal cuff. TIP: It is important to properly label the proximal and distal cuffs and their respective valves to avoid deflation of the wrong cuff and the abrupt loss of anesthesia that would ensue or risk of local anesthetic toxicity.

Proper procedure of deflating the tourniquet at the end of surgery is also important to avoid the risk of local anesthetic toxicity when the procedure is completed within 45 minutes after the injection of local anesthetic. A two-stage deflation is suggested whereby the cuff is deflated for 10 seconds and reinflated for 1 minute before the final release. This practice allows for a more gradual "washout" of local anesthetic. Complications and How to Avoid Them Complications of intravenous regional blocks are few and are mostly limited to systemic toxicity from the local anesthetic that is related to problems with the tourniquet.

Systemic toxicity of local anesthetic

The risk mainly comes from an inadequate tourniquet application or equipment failure at the beginning of the procedure Every precaution should be undertaken to ensure that the tourniquet is reliable and the pressure is maintained Gradually release the tourniquet in two steps to prevent a massive "washout" of local anesthetic When the surgical procedure is completed, within 20 minutes after injection of local anesthetic, gradually release the tourniquet in several steps, with 2-minute intervals between deflations. Use a small gauge IV catheter When the superficial veins are punctured during an unsuccessful attempt at placement of the IV catheter, apply firm pressure on the puncture site for 2-3 minutes. Failure to do so will invariably lead to venous bleeding during application of the Esmarch. Ensure that the tourniquet is fully functional and that the arterial pulse is absent This scenario may be more common in patients with arteriosclerosis; the calcifications in the arterial walls prevent effective function of the tourniquet; consequently, the arterial blood continues to enter the distal extremity while the venous blood is unable to escape, resulting in engorgement of the extremity and occasionally echimotic hemorrhage in the subcutaneous tissue. The above principle applies. Assure that adequate padding is employed over the arm where the application of the tourniquet is planned.

Hematoma

Engorgement of the extremity

Exchomoses and subcutaneous hemorrhage